cast verification form.doc
TRANSCRIPT
FORM-17
FORM-16
( Rule No.14)FOR GOVERNMENT/SEMI GOVERNMENT EMPLOYEES
SERVICE
SERVICE
APPOINTMENT/PROMOTION APPOINTMENT/PROMOTION
Application Form for verification of Scheduled Caste/Scheduled Caste
converts to Buddhism/De-Notified Tribe (Vimukta Jati)/ Nomadic Tribe/Other
Backward Class/Special Backward Category certificate to be submitted to Divisional Caste Certificate Scrutiny Committee.
Affix Passport size Colour Photo
To,
Member Seceretary and Research Officer,
Divisional Caste Scrutiny Committee, No.........
............................................
Sub :- Verification of Scheduled Caste/Scheduled Caste converts to
Buddhism/De-Notified Tribe (Vimukta Jati)/
NomadicTribe/Other Backward Class/Special Backward
Category Caste certificate
(Strike out whichever is not applicable)
Sir,
I, the undersigned Shri/Smt/Kum.........................................................presently working/ have been appointed/to be promoted as..................at................................Department from Date ............... under reserve Category of Scheduled Caste/Scheduled Caste converts to Buddhism/De-Notified Tribe (Vimukta Jati)/Nomadic Tribe/Other Backward Class/Special Backward Category. I hereby request to verify my caste certificate. Following information and documents are submitted herewith in support of my caste claim.
1(a) Full name of the Applicant (as mentioned in caste certificate)and present address.........................................................................
.........................................................................
..................................Pin Code........................
(b) In case of married female applicant, name prior to marriage...........................................................................
...........................................................................
(c) Mobile No.
(d) E-Mail
2Caste/Sub Caste claimed by applicant...........................................................................
3Applicant's a) Birth date
b) Birth place...................................................................
...................................................................
4Full Name of applicant's Father and Permanent Address
(If Father is not alive please mention full address of his last Residence.)......................................................................Village/Town..............................................
Taluka...........................................................
District..........................................................
Pin Code.......................................................
5Full Name of applicant's Grand Father (Father's Father)---------------------------------------------
6Present occupation/service of applicant's father with telephone number and address---------------------------------------------
............................................................
7Father's Education............................................................
8Inherited profession of Family............................................................
...............................................................
..................................................................
11Name of the competent authority from whom caste certificate is obtainedI
And Certificate No. and Date..................................................................
..................................................................
...................................................................
12Name of the document on which basis caste certificate is obtained from competent authority...................................................................
...................................................................
...................................................................
13. Details of institution where applicant studied
Stage of EducationName of Educational
Institute and AddressDuration of Education (Year)Caste mentioned in educational institute's record
(a) Primary
Education
(i.e. give sufficient
details from Std.l)
(b) Secondary
Education
(c) College
Education
14. If applicant's father is literate following information to be furnished
Stage of EducationName of Educational
Institute and AddressDuration of Education (Year)Caste mentioned in educational institute's record
(a) Primary
Education
(i.e. give sufficient
details from Std.l)
(b) Secondary
Education
(c) College
Education
15. If applicant/applicant's family is migrated in Maharashtra from other State, following information is to be furnished:-
Is applicant's family is migrated to Maharashtra State? If yes, from which State and when (Year)?.........................................................................
.........................................................................
.........................................................................
16(a) Whether scrutiny of the caste certificate of any member of the family has done
earlier? If yes
Name of family member, his relation with applicant and why and when
scrutinized?
(b) If Validity Certificate is received
give its Number and Date (enclose
attested copy)
(c) If rejected give its details .....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
17(a) If applicant has applied for caste certificate before any committee in
the state.
If yes, (b) which committee
(c) For which Caste
(d) Date of application
(e) Committee's decisionYes/No
.....................................................................
.....................................................................
.....................................................................
Valid/Invalid
18Applicant's present employment details
(a) Name and address of the office
(b) Date of appointment, if appointed.
(c) Purpose of scrutiny.....................................................................
.....................................................................
.....................................................................
.....................................................................
For promotion/new appointment in reserved category
(Strike out which is not applicable)
Documents to be attached with application
(Strike out whichever is not applicable)
(a-1)Original Caste Certificate of ApplicantAttachement Compulsary
(a-2)Certified copy of Caste Certificate of ApplicantAttachement Compulsary
(a-3)Certified Copy of Applicant's Birth DateAttached Yes/No
Attached Yes/No
(a-5)Certified Copy of Applicant's Father Primary School
Leaving Certificate/ School Register's ExtractAttached Yes/No
Certified Copy of School Leaving Certificate/ School Register's Extract of Grand Father/ Real Elder Uncle/Real Aunt (From Paternal side)
Attached Yes/No
(a-7)Original Affidavit (in Specimen Form-3 and Form-15A to be obtained from College/Caste Scrutiny Committee Office)Attached Yes/No
(B) Important Secondary Documentary Evidence * (If above Primary Documentary Evidence are not available)
Attached Yes/No
OR
If Caste is not mentioned in above documents, then, Revenue Record / old purchase/sale deed in which caste is mentioned
(b-2)Any other documents supporting caste claimAttached Yes/No
(b-3)If any of the above documents are not available, then attach other relevent documents. (mention)......................................................................................................
I am producing certified copy of above documents with my application. I declare on oath that the information furnised by me in this application is true and correct. I am aware that incomplete application will be rejected and responsibility of making fresh application will be of mine.
Place :
Yours
Date
Applicant's signature.
CERTIFICATE OF APPOINTING AUTHORITYThis is to certify that Shri/Smt.................................................................................................
is working/under consideration for appointment/promotion for the post of ..............., since this post is reserved for Scheduled Caste/De-Notified Tribe (Vimukta Jati)/Nomadic Tribe/Other Backward Class/Special Backward Category, the validity of his /her caste certificate is necessary. So it is requested to verify his /her caste certificate. (Strike out whichever is not applicable)
Place :
Date :
Sign & Stamp of the
Appointing Authority
Impoprtant Instructions:
(a) If Claim for Schedule Caste, Caste evidences should be prior to 10th August, 1950.
(b) If Claim for De-notified Tribes (Vimukta Jatis), Nomadic Tribes, Caste evidences should be
prior to 21st November, 1961.
(c) If claim for Other Backward Class and Special Backward Category, Caste evidences should be prior to 13th October, 1967.
(d) In addition evidences of residents of above mentioned period is essential for applicant who
has migrated in Maharashtra form other State.
(e) Migrants from other state to Maharashtra after above mentioned period whose Caste Certificate is in "Migrants" format should not apply to committee.
FORM 16-A
(Rule No. 14)
For Government / Semi Government Employee
Affidavit to be submitted with application of Caste Certificate Verification
I Shri / Smt. --------------------------------------------------------------age ------------- year, Occupation----------------------, residing at -------------------------------------------------------, hearby solemnly affirm today dated ------------------ that caste certificate Number-------------------------------dated----------- given by Tahasildar and Execiutive Magistrate/Deputy Collector/Sub Divisional Officer---------------- District is submited for the Scrutiny.
Validity Certificate is required for my Appointment/Promotion in reserved category.
The documents and proofs attached with the application Form are obtained by me from Competent Authority. These documents are true and correct and obtained by followig proper procedure. No alteration / correction / change are made in these documents. I affirm hereby that these documents are not duplicate or bogus.
*Caste Certificate of any relative from my paternal side was not invalidate by the Scrutiny Committee.
*And it is not a case that I applied before any Caste Certificate Scrutiny Committee in Maharashtra and my caste certificate is invalidated.
I will be resposible, if the documents and proofs attached with the application form are found to be incorrect or bogus, and I am aware that I will be libale for punishment under provision of Indian Penal Code.
I declare that the above mention information is true and correct, hence this affidavit.
Place :-
Signature of the Declarant
Date:-
(*Delete which is not applicable)FORM 3
[rule 4(1), 14]
AFFIDAVIT OF CLAIMANT/PARENT(S)
(Order 18, rule 4 of the Code of Civil Procedure,1908)
1.I,...........................................,son/daughter of Shri/Smt................................, aged ......... years, occupation................................, residing at ............................. village/Town, ......................... Tahsil,................................ District, ................ State, hereby solemnly affirm as under :-
2.I hereby give the genealogy tree of my family and relatives, which is as under-
3. Other relevant submissions to be made or any essential explanation to be made, in support of Caste/Tribe claim, including the sociological, anthropological and ethnological (anthropological moorings and ethnological kinship), genetical traits, of the Caste/Tribes, if any;
To the best of my knowledge and belief the information given in the application form and in this affidavit is based on facts and is correct.
Place :
Signature.......................................
Date :
(Name of the applicant/ claimant)